Comparing different surgical techniques used to remove wisdom teeth from the lower jaw (2023)


The removal of wisdom teeth is a common operation, but it can cause short- and long-term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition.

Review question

We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long-term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw.

Study characteristics

We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative.

Key results

The available evidence is inconclusive.

It is unclear if the position of the cut into the gum makes any difference to the outcomes.

It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor.

(Video) Impacted Tooth Removal

It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected.

It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes.

It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes.

Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction).

Another three surgical approaches were tested in the studies, but they did not measure the important outcomes.

Certainty of the evidence

None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.

Authors' conclusions:

In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty.

Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars.

Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

(Video) Lower wisdom tooth surgical extraction

Read the full abstract...


Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.


To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

(Video) Fast lower wisdom tooth surgical extraction

Search strategy:

Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

Selection criteria:

Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

Data collection and analysis:

Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

(Video) Lower wisdom tooth extraction with section of cervical area

Main results:

We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy.

There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions.

There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison.

There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported.

There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects.

There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes.

Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.


What are the different types of wisdom teeth removal? ›

The four types of wisdom teeth removal are:
  • Nonimpacted wisdom teeth removal.
  • Soft tissue impact removal.
  • Partial bony impact removal.
  • Complete or full bony impact removal.
Jan 13, 2021

How are lower wisdom teeth removed? ›

Removing the wisdom tooth

If the tooth hasn't come through the gum, a small cut (incision) will be made in the gum to access it. A small piece of the bone covering the tooth may also need to be removed. The tooth may be cut into smaller parts to make it easier to remove through the opening.

What is the best option for wisdom teeth removal? ›

Because wisdom teeth removal is a more complicated extraction than other tooth removals, and because you may have two or even all wisdom teeth removed at once, sedation dentistry is a really good option for this procedure. You can be sedated mildly or even be under general anesthesia.

What is the most difficult wisdom tooth extraction? ›

Full-Bony Impacted: This type of wisdom tooth removal is the most difficult because the wisdom tooth is completely stuck in the jaw.

What is the easiest wisdom tooth to remove? ›

Upper wisdom teeth are often easier to remove than lower ones, which are more likely to be impacted. Your dentist will say whether the tooth should be taken out at the dental practice, or whether you should be referred to a specialist (oral surgeon) at a hospital.

What are the 4 types of wisdom? ›

“There are four classes of wisdom, according to James 3:15-17: earthly wisdom, intellectual wisdom, devilish wisdom and the wisdom from above,” he explained.

How long does it take to recover from a lower wisdom tooth extraction? ›

It can take up to 2 weeks to recover from the surgery for having your wisdom tooth or teeth removed. During this time, you may have: a swollen mouth and cheeks – this will be worse for the first few days but will gradually improve; gently pressing a cold cloth to your face helps reduce the swelling.

Why is it harder to remove lower wisdom teeth? ›

Wisdom teeth, however, aren't as easy to extract as other teeth. This due to things like the angle of the tooth, the solidity of the jawbone and dealing with multiple roots at once.

How long does it take to remove bottom wisdom teeth? ›

It takes anything from a few minutes to 20 minutes, or sometimes even longer, to remove a wisdom tooth. After your wisdom teeth have been removed, you may have swelling and discomfort, both inside and outside your mouth. Occasionally, some mild bruising is also visible.

Can you choose to be put to sleep for wisdom teeth removal? ›

Before beginning your surgical treatment plan, your oral surgeon will discuss your options, explain the benefits and potential drawbacks, and help you find the best sedative option. If you need to be put completely to sleep during your procedure, oral surgeons can typically accommodate you.

What is the most common sedation for wisdom teeth removal? ›

Also known as laughing gas, nitrous sedation is the most common method used during dental procedures including wisdom teeth removal because it is minimally invasive.

When do wisdom teeth removal hurt the most? ›

With a typical wisdom tooth extraction, discomfort typically improves after 3 or 4 days, with day three usually being the most noticeable in regard to discomfort. If you are developing an infection or dry socket, the pain may last as long as two weeks without professional treatment.

What are the worst cases of wisdom teeth? ›

Complications of Wisdom Teeth Eruption

Cysts: painful tumors or cysts can develop in the gum tissue surrounding the wisdom teeth at the site of impaction, sometimes becoming infected. Tooth Decay: partially erupted teeth can be extremely hard to clean, especially if there is very little tooth above the gum line.

How traumatic is wisdom tooth extraction? ›

Particularly for older adults, the pain and discomfort of having wisdom teeth out is in the days and weeks after surgery. It's a very physically aggressive procedure to one of the most sensitive parts of the body, and although mouth tissue heals quickly, there is internal bruising and facial muscle stress.

What makes a wisdom tooth removal complicated? ›

• Complex Wisdom Teeth Extraction

When wisdom teeth are impacted, meaning they are hidden beneath the gum line and are often angled, a complex wisdom teeth extraction is required. This procedure requires an incision and usually requires general anesthesia and the skill of a dental surgeon, like our doctors.

How long is a wisdom teeth surgery? ›

Your surgery should take 45 minutes or less. You'll get one of these types of anesthesia so you don't feel pain during the removal: Local: Your doctor will numb your mouth with a shot of local anesthetic such as novocaine, lidocaine or mepivicaine.

Do wisdom teeth have deep roots? ›

Wisdom Teeth Removal Might Be More Complicated

These deeper roots run close to certain nerves, which can be damaged during wisdom tooth removal, potentially causing permanent numbness.

What are the 7 Pillars of wisdom? ›

Wisdom's seven pillars, according to scripture, are: fear of the Lord, instruction, knowledge, understanding, discretion, counsel, and reproof.

What are the three levels of wisdom? ›

On the first level, there is analytical-rational wisdom, on the second level, there is intuitive-experiential sensitivity, and on the third level, there is actual philosophical wisdom.

What are the 6 components of wisdom? ›

Previous studies have identified six common, measurable components of wisdom: pro-social behaviors (empathy, compassion, altruism and a sense of fairness), emotional regulation, self-reflection or insight, acceptance of divergent perspectives, decisiveness and social decision-making.

Does lower wisdom tooth extraction hurt? ›

So, wisdom tooth removal does it hurt? During the procedure, you should feel no pain and barely any (if at all) discomfort. After the procedure, the extraction site may feel a little tender for several days but with a little rest and recuperation, you should be back to normal within 7 days.

Do lower wisdom teeth heal slower? ›

In most cases, the wisdom teeth on the upper jaw heal faster than those on the lower jaw. The difference in healing time is mainly due to the higher density of the lower jawbone, which means it takes longer to achieve sufficient jawbone growth to replace the empty region.

Does lower wisdom tooth extraction hurt more than upper? ›

The Difference in Bone Structure

The bone that holds your lower set is far stronger and denser. On the other hand, the bone that holds the upper set is not as strong or dense. It is no surprise that the extraction of your upper wisdom tooth is not as painful.

Does lower wisdom teeth removal change face shape? ›

So, Will Wisdom Tooth Surgery Affect Facial Shape? In short, no, at least not for the long term. Even though removing large teeth can sometimes come along with slight changes to the shape of your face, the same does not usually apply to wisdom teeth.

Can a dentist remove bottom wisdom teeth? ›

Wisdom tooth removal can be carried out by a dentist or a specialist surgeon working in a hospital. If your dentist recommends removing your wisdom teeth, they'll take an X-ray of your mouth to help them determine who should carry out the procedure.

How many teeth do you have on the bottom row with wisdom teeth? ›

If a person does not suffer an injury or contract a disease which results in them losing one or more teeth, an adult will most commonly have the same number of teeth on the bottom half of their jaw as the top. This means that they will have 16 teeth on the bottom row as well as on the top row.

What not to do after wisdom teeth removal? ›

Do not rinse your mouth too vigorously, suck on a straw, or drink carbonated beverages for the first 24 hours. Do not smoke or drink alcohol – Do not smoke or drink alcoholic beverages for at least 48 hours after surgery and preferably not for the first week.

How many teeth should you have on bottom including wisdom teeth? ›

Teeth are essential. They help people talk, chew, and swallow food. Adults typically have 32 teeth, four of which are wisdom teeth. One 2019 article states that a full set of adult teeth consists of 16 lower teeth and 16 upper teeth.

Is it better to be awake or asleep for wisdom teeth removal? ›

It depends on your wisdom teeth, your mouth, and your comfort with dental work. If your wisdom teeth are deeply impacted, you may need more sedation than you would if you weren't having any problems yet.

What can you not do the night before wisdom teeth removal? ›

You may not have anything to eat or drink (including water) for eight (8) hours prior to the appointment. No smoking at least 12 hours before surgery. Ideally, cut down or stop smoking as soon as possible prior to the day of surgery.

Should I be awake or asleep for wisdom teeth? ›

Before you receive an injection, your dentist or surgeon will likely apply a substance to your gums to numb them. You're awake during the tooth extraction. Although you'll feel some pressure and movement, you shouldn't experience pain.

What drugs do they give you after wisdom teeth removal? ›

Most likely after your wisdom teeth removal, your oral surgeon may prescribe you Vicodin and hydrocodone, the most common opioid-based pain relievers after your surgery. Some dentists recommend opioid-based medicines like Vicodin or Tylenol with Codeine for their patients.

How long does it take to be sedated for wisdom teeth? ›

General anesthesia used for wisdom teeth removal, where the patient is put to sleep during the procedure, takes about 45 minutes to an hour to wear off. During this time, you might feel sleepy or confused, this is why we strongly suggest that the patient have a designated driver or scheduled transportation.

What drug is used for IV sedation wisdom teeth? ›

In the dental industry, th most popular class of drugs used for IV sedation are benzodiazepines, which include diazepam (Valium), lorazepam (Ativan) and midazolam (Versed).

Can I go to work the next day after wisdom tooth extraction? ›

Most people can go back to work or school in two to three days after wisdom teeth extraction. However, if your job requires physical labor or heavy lifting, you may need to take a few extra days off of work.

What can I eat on day 2 after wisdom teeth removal? ›

For 2 days after surgery, drink liquids and eat soft foods only. Such as milkshakes, eggnog, yo- gurt, cooked cereals, cottage cheese, smooth soups, mashed potatoes, refried beans, ice cream, pudding, fruit smoothies and protein shakes.

What happens on day 5 of wisdom teeth removal? ›

Days 5-7: Most symptoms should subside except limited jaw opening and a minor, occasional ache. It may take 2-4 weeks to reach normal Jaw opening. If any stitches remain, you should return to your dentist to have them removed.

What happens if a nerve is damaged when removing wisdom teeth? ›

Nerve injury

Although far less common than dry socket, injury to sections of a nerve called the trigeminal nerve is another possible complication of wisdom tooth removal. It can cause pain, a tingling sensation and numbness in your tongue, lower lip, chin, teeth and gums.

How many wisdom teeth dies a person have? ›

Of the 12 molars, there are four wisdom teeth. A person will have a complete set of permanent, adult teeth by their teen years, and commonly, the four wisdom teeth are removed so the other teeth can grow in comfortably. Removing the wisdom teeth also helps to prevent misalignment of other permanent teeth.

What are the benefits of keeping your wisdom teeth? ›

In fact, where they are not negatively impacting oral and/or overall health, it is best to keep wisdom teeth intact. Properly erupted wisdom teeth provide support in the back of the mouth and help maintain bone in the jaw. This support is beneficial to the health of the temporo mandibular joint (TMJ).

How many people get nerve damage from wisdom teeth removal? ›

Injury to the inferior alveolar nerve, which runs within a bony canal within the mandible running close to the root apices, will occur in about 6% of third molar removals; one in ten of these will not recover. Permanent lingual nerve injury occurs in approximately 1 in 200 wisdom tooth removals.

Why do people get emotional after wisdom tooth removal? ›

It is common to cry and suffer from emotional behavior after your treatment. This is due to your anesthesia and will not last long. Dr. Michael Shnayder recommends that you remove your gauze after 45 minutes.

Are you more likely to get sick after wisdom teeth removal? ›

Nausea and vomiting are common after wisdom tooth removal. In some cases, patients feel nauseous after anesthesia. To help your nausea you can sip coke or ginger ale to help the feeling subside. Typically, nausea should go away after 4-6 hours.

How often are there complications with wisdom teeth removal? ›

Up to 1 out of 100 people may have permanent problems as a result of the procedure, such as numbness or damage to nearby teeth. The risk of this happening will depend on how extensive the procedure needs to be. Wisdom teeth are typically removed under local anesthesia.

How can I stop worrying about wisdom teeth removal? ›

Progressive muscle relaxation, deep breathing exercises and meditation can work to lessen your worries about wisdom tooth extraction. Learn a few techniques and take time to practice them before your procedure, and you'll be able to put them to use on the day of your oral surgery.

What is the difference between impacted and erupted wisdom teeth? ›

Fully impacted wisdom teeth reside completely underneath the gum tissue and are unable to break through. Partially erupted wisdom teeth are those that have partially broke through the gum tissue, but are still partially underneath the gum tissue.

What are the 4 impacted wisdom teeth? ›

Impacted wisdom teeth happen when your third molars become partially or fully trapped in your gums or jawbone. This can lead to a number of oral health problems, including infection, tooth decay and gum disease. Surgical removal is often recommended as treatment for impacted wisdom teeth.

Is horizontal wisdom tooth extraction painful? ›

Just like it sounds, a horizontal impaction is one in which the tooth is angled completely on its side (horizontally). It is usually the worst and most painful type of wisdom tooth impaction to have, and is often completely under the surface of the gum and pushed against the molar next to it.

What are the risks of a coronectomy? ›

The most common and severe complications of third molar extraction surgery include dry socket, postoperative infection, alveolar bone fracture, oroantral communications, damage of inferior alveolar nerve or lingual nerve, and mandibular fracture in rare cases.

Why is bottom wisdom teeth harder to remove? ›

The Difference in Bone Structure

The bone that holds your lower set is far stronger and denser. On the other hand, the bone that holds the upper set is not as strong or dense. It is no surprise that the extraction of your upper wisdom tooth is not as painful.

How long does it take to heal from non impacted wisdom teeth removal? ›

How long does it take to recover from non-impacted wisdom tooth removal? You should expect full recovery from your wisdom tooth procedure to take about 10-14 days if proper care is taken.

Can you remove a wisdom tooth that hasn't erupted? ›

If the wisdom tooth has not fully erupted into the mouth it is often necessary to make a cut in the gum over the tooth. Sometimes it is also necessary to remove some bone surrounding the wisdom tooth. The tooth may need to be cut into 2 or 3 pieces to remove it.

How long does 4 impacted wisdom teeth take? ›

Most wisdom tooth removal surgeries last about 40-90 minutes. Even if you're having all four of your wisdom teeth removed at once, the procedure typically takes an hour. If your wisdom teeth are in a difficult position or there are unexpected difficulties, the surgery may take a bit longer.

How long is wisdom teeth surgery? ›

Your surgery should take 45 minutes or less. You'll get one of these types of anesthesia so you don't feel pain during the removal: Local: Your doctor will numb your mouth with a shot of local anesthetic such as novocaine, lidocaine or mepivicaine.

Are impacted wisdom teeth always removed? ›

Your wisdom teeth don't usually need to be removed if they're impacted but aren't causing any problems. This is because there's no proven benefit of doing this and it carries the risk of complications.

How long does it take to heal from horizontal wisdom teeth removal? ›

Recovery From Dentist Wisdom Tooth Extraction

You should feel better in 2 or 3 days after an extraction. Many people need to rest for about 5 days after a surgical wisdom tooth removal, however. You should feel like resuming normal activities in 10 – 14 days after an impacted wisdom teeth removal.

When does wisdom tooth surgery hurt the most? ›

With a typical wisdom tooth extraction, discomfort typically improves after 3 or 4 days, with day three usually being the most noticeable in regard to discomfort. If you are developing an infection or dry socket, the pain may last as long as two weeks without professional treatment.

How painful is a coronectomy? ›

As it is a surgical procedure, there will be soreness after the tooth removal. This can last for several days. Painkillers such as ibuprofen, paracetamol, Solpadeine or Nurofen Plus are very effective. Obviously, the painkiller you use is dependent on your medical history & the ease of the operation.

Are you awake for a coronectomy? ›

You are awake but patients frequently have little or no memory of the operation. General anaesthetic- it is possible to have a coronectomy under a “day case” general anaesthetic, ie although you are put to sleep completely you will be able to go home on the same day as surgery.

How long does coronectomy surgery take? ›

The crown of the tooth is removed with the drill and the remaining root surface smoothed down. The gum is then put back into position and stitched into place. The procedure usually takes 30-40 minutes.


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